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Saturday, April 27, 2013

A contrarian view of medication compliance II

I previously blogged about my recent patient encounter which a patient who had been less than entirely compliant with her medication for her chronic and uncomfortable condition. In this blog, I want to expand upon my thoughts regarding patients and medication compliance. In the previous piece, the patients I wrote about had every reason to want to take their treatment. They were uncomfortable and sought relief from their discomfort. They had a current problem which gave them little or no opportunity to forget they had a problem.

However, when we prescribe medications, we often do so to prevent some sort of symptomatic and obvious problem that MIGHT happen at some undefined point in the future. We therefore make recommendations to patients who might feel absolutely fine in the present. They are by most measures and definitions well people. We may be selling them on something they neither need nor want.

 I can't help but think of Clayton Christensen' observation in the "Innovator's prescription" where he studied patrons of a fast food restaurant who purchased milk shakes on their way to work. When the restaurant tried to increase sales, they did so by offering more variety. It did not work. The customers wanted convenience, not variety,  and sales went up when a self serve station was deployed. His take on this scenario was that it is difficult to sell people a product that they simply don't desire.

In that same light, when we treat asymptomatic states and make every effort to get people to undertake activities from which they gain no immediate (and perhaps no long term) benefit(s), are we not trying to sell them a product which, if adequately informed, might be something they do not want? This is particularly an issue if our desire to push therapies goes beyond evidence that these interventions provide actual benefits to those treated.

 Take for example treatment of moderate hypertension. Quality metrics and physician bonuses may be tied to hitting specific milestones of hypertension control in managed populations. Even under the best of circumstances, one needs to understand that there will be hundreds if not thousands of patients treated for every one who might benefit. In fact, recent data would suggest that for modest hypertension, there may be no benefit whatsoever. (http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006742.pub2/abstract)  Given the vagaries of the data, one would anticipate that patients should be ambivalent about buying a product that likely will provide them with no person benefit. This may only get worse as our strident pleas to address critical issues are followed up my "never minds" which come as a consequence more complete assessments..

The automobile dealer from which I bought my care contacts me on a regular basis trying to get me back in their shop to have regular maintenance done. They are vested in getting me back there and I am sure they can make the case that it is important from a safety perspective to have my brakes and tires checked and to make sure that no critical part will fail at a critical time. Manufacturers have installed various warning lights to create a sense of urgency to prompt us to bring our vehicles in, even if they appear to be functioning fine. These lights send the signal that something bad might happen unless we act. We and most of the public understand they are in business and their actions are driven by their desire to maintain cash flow and a healthy bottom line. Individual vehicle owners may benefit from their efforts to drum up business as well the the only certain benefits is that obtained by the dealership.

There is a point where our actions and recommendations the health care industry as to how patients should behave and adopt our recommendations will be viewed by the general public in the same way as how we view our car dealers calling us and telling we need to have work done. When we make a recommendation for a single patient or groups of patients that a specific treatment is desirable, how likely is it that an individual patient will benefit from the specific intervention? For the most part we don't know and if we do not know, we should be careful about being particularly strident about adoption of our recommendations or critical of those who fail to heed our warnings.

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